Malawi’s first National Child Oral Health Survey – fieldwork completed!

This is a guest post written by Lisa Taylor, with input from all the colleagues named in the narrative who participated in this national Child Oral Health Survey, undertaken in Malawi in October 2023.

Following the successful launch in April 2022 of the National Oral Health Policy for Malawi, attention has now turned to implementation. Prevention of dental caries in children is one of the key aims, so the next logical step was to carry out an epidemiological dental survey to determine the current oral health status of the child population. Armed with this knowledge, an assessment could be made in the future about the impact of any oral health interventions.

The survey was in the planning phase for a significant period. The delay was in part due to COVID, but it also took a considerable time to gain permissions from the Malawi Ministries of Health and Education, and ethical approval from the National Health Sciences Research Committee. Grateful thanks are due to Peter Chimimba and Lorna Macpherson for their efforts in this regard. Finally the survey was ready to proceed in October 2023. This blog aims to give an insight into the process of delivering the survey in Malawi.

Initially, a team from the UK and from Malawi was brought together under the leadership of Jeremy Bagg. This comprised Martha Chipanda, at that time the Oral Health Coordinator in the Malawi Government Ministry of Health, Peter Chimimba, the Lead for the MalDent Project at Kamuzu University of Health Sciences, Lorna Macpherson and David Conway, both Professors in Dental Public Health from Glasgow Dental School, Alex McMahon who is a statistician / epidemiologist at Glasgow Dental School, the Smileawi team (Nigel and Vicky Milne) who had previously undertaken a pilot child oral health survey in Malawi, and me as a dentist with previous experience as a VSO dentist in Malawi and UK experience of BASCD (British Association for the Study of Community Dentistry) surveys and of the National Child Oral Health Survey.

Meetings were held over zoom and the project grew over several such discussions. The protocol was developed and followed the WHO Pathfinder format for oral health surveys. It was decided to examine 6 year olds and 12 year olds, as these children are still in primary school in Malawi, making them more accessible. Alongside the clinical examination, two written questionnaires were also developed in conjunction with our Malawian colleagues to enable other social contributors to oral health to be explored. One was for the headteacher of each school and one for each child examined.

The Glasgow Dental School Dental Public Health and Epidemiology team working with colleagues from Malawi determined the number and location of schools to ensure a representative sample. Decisions were made with regard to the training and calibration programme and detailed documents written. These were sent to Malawi to assist in the preparation of their dental teams who would be undertaking the survey, together with preliminary training material for them to work through in advance of the face-to-face training. In addition, Martha Chipanda identified the dental therapists and dentists who would be involved in the project and the team administrators contacted the school that would be involved in the training and calibration exercise.

In October 2023, Nigel, Vicky, myself and my husband, Chris, flew to Malawi to carry out the training and calibration exercise. 

The pilot study carried out by Nigel and Vicky had confirmed the importance of having a survey administrator. Chris’s role was to capture the training and calibration data and to transmit this live for statistical analysis by the Glasgow team. They in turn gave live feedback to the trainer, who could use this to best support the training.

Initial meetings with the Malawi team prior to starting the face-to-face training enabled any challenges to be identified and solutions planned.

The Malawian dental team members were given face-to-face training in adapted BASCD criteria for undertaking surveys.

Interactive training and discussions were also undertaken to enable the Malawian team to plan how they would carry out the survey and to consider any potential difficulties they might face during the survey – not that we could prepare them for everything!  

Following the theoretical teaching a training exercise was undertaken, working with 6 year olds and 12 year olds.

The children seemed to enjoy the exercise:

Feedback was given following the training to help prepare the dental team for the all-important calibration exercise the following day.

The calibration exercise was undertaken with both 6 year old and 12 year old children.

Oral examination data were carefully collected from the children participating in the calibration course, who were examined separately by each of the examination teams. The data were sent electronically by Chris to the Glasgow Dental School team who assessed the results for inter-examiner agreement. Fortunately, all examiner teams passed the calibration and so were able to take part in the formal survey.

The team members were now trained, calibrated and ready to go.

On the first day of the survey it became clear that the examining teams needed to be larger due to the time required to work through the questionnaire with each child.  A meeting was held with the whole group to plan how best to proceed.  The Malawian team members were very flexible and the idea was evolved to divide the group into two larger teams, rather than the three smaller teams initially planned.  This proved to be very successful on the second day and was continued throughout the survey.

We were always given a warm welcome at the schools we attended with great excitement from the children:

The UK team continued the training of the Malawi team for the first couple of schools to ensure they were happy with how to apply all the dental survey criteria. 

Chris supported the administrative teams to keep track of all the survey forms and to ensure no child was missed from the examination.

The teams proved to be very competent and confident in carrying out the survey.  Following this additional ‘in school’ training, the UK team then acted as additional manpower to ensure as many children as possible were examined.  

There was a lot to do with completion of questionnaires and delivery of oral health advice, in addition to the examinations themselves.  These activities took place in a variety of locations depending on the layout of the school and proved the flexibility of the survey team.  

Following the initial excitement of our arrival, the children were generally very patient waiting for their dental examination, clutching their completed questionnaires

The UK team really enjoyed supporting our Malawian colleagues, but time constraints meant that we had to leave them to complete the survey without us.

We knew they were ready to go it alone and they sent photos to prove it:

They even managed to overcome some unexpected challenges!

In this way, 2994 children were included in the survey, one of the first of its kind in sub–Saharan Africa. The data have been securely transferred to Glasgow Dental School, where data entry and analysis are currently underway. A report will be written and disseminated in due course.

The experience of carrying out the survey was really satisfying.  The Malawian team members were very enthusiastic in their approach which contributed to the success of the survey.  They seemed to enjoy being part of Malawi’s first oral health survey of these age groups.  I’m sure they will now have the confidence to undertake a future survey when required … and if they have any questions, they can always call on their friends!

Acknowledgements

Grateful thanks are due to the teachers and pupils in the schools visited, whose willing engagement made the survey possible. In addition to the dentists and dental therapists performing the study, the organisational and administrative support provided by colleagues from the Kamuzu University of Health Sciences, working with Chris, is gratefully acknowledged.

Significant financial support was provided by The Borrow Foundation, and by Scottish Government International Development via the MalDent Project. We are very grateful to these two sponsors without whose support the study would not have been possible.